Debate with PHTLS (NAEMT) Instructor

[paramedicmike]

What kind of corroborating signs are you looking for? Do you think it will make a difference? The subject is pulseless, apneic with a hole in his/her head. S/he is dead.

I have found individuals in this manner before. S/he was dead when I arrived. Nothing was going to change that fact. I did not work the individuals in question.

[Kiwiology]

The guy is dead it's as simple as that

Whether your "local protocol" conforms to whatever flavour of alphabet soup class being taken is another question entirely

Now if you'll excuse me I have to go to the Resident Medical Officer lounge and eat the House Surgeons lunch, he died from fatigue so wont be needing it no more

[DwayneEMTP]

I get what you're saying LS, but what do your protocols say about traumatic arrest in general?

[Kiwiology]

I get what you're saying LS, but what do your protocols say about traumatic arrest in general?

I wish I got what you were saying, I can't understand your white trash speak and you're probably fucking drunk half the time anyway

Georgia Protocol (1) states on page 1-9

... obviously fatal trauma should have resuscitation withheld

Again, as to whether or not this conforms to the alphabet soup class way of teaching .... eh that's like following Alice down the rabbit hole, and the bloke who wrote that was high on mushrooms or something at the time so hey, y'know it kind of all makes sense

This is why we don't have alphabet soup classes.

Lone, I know you're an intelligent bloke (sure, you're a bull headed prick some of the time and I want to kick the shit out of you with my safety boots) and I know how much you want to better yourself and see the profession advance; this is admirable and it has been obvious from the outset of our exchanging ideas and insults that you get very frustrated with the current complexities and inconsistencies and discombobulations that constrain you.

Such desire for betterment is admirable.

(1) http://ems.ga.gov/pd...15-08%20Web.pdf

Edited February 10, 2012 by kiwimedic

[systemet]

The issue I'm having is that there's the PHTLS way, the BTLS way, the Mosby way, the NAEMT way, the NREMT way....ad infinitum.

This is frustrating, but it's a consequence of multiple different organisations trying to shove a bunch of grey into a series of nice box and arrow flowchart.

As EMTs and Paramedics we're not generally intelligent consumers of information. If I was king, this would change. Our practice is dictated, at least partially, by the body of available medical evidence. We should be taught how to access this, and we should be able to critically evaluate it, and we should be framing our conversations on website such as these in terms of the available data, where it applies. I believe we're moving in that direction.

Personal opinions: Mosby has never published a decent textbook on any aspect of EMS that is suitable beyond the EMT level. NAEMT is useless, the only value some of their courses have are in extending the limited training most of us get at a basic level. NREMT probably serves a purpose in the US for reciprocity. I haven't worked out how it affects any of us outside of the US in any way.

PHTLS / BTLS are almost skills courses. I feel that they're next to useless. They essentially tell you to immobilise unconscious/altered trauma patients, pay a brief lip service to the far more valuable issue of selective immobilisation in minor trauma, and brief discuss IO / IV access, without any reasonable discussion about fluid replacement, the use of different fluids, problems with over-resuscitation, in-hospital treatment of trauma, advanced diagnostics, or even something as directly relevant to prehospital care as RSI. Mostly we get some sort of poor variant of there's JVD, hypotension and absent lungs sounds --> needle decompression.

Let's all get on the same page here and come up with a single way of doing things, answering questions and treating our patients based on the evidence that we uncover during our exams (be it trauma/medical/focused/rapid etc).

I think a better solution is for us actually to get educated in trauma care beyond the latest children's chewable, wipe-clean, story book that NAEMT / ACS wants to put out for prehospital providers. But I understand your frustration.

To me, having certain criteria that has to be met before we can just "call 'em dead" is the only logical method I can think of. When we come to the scene of a cardiac event, do we simply pronounce the patient 'dead' because we can't get a pulse or because the monitor shows asystole in only one lead? Absolutely not! We look further int the situation (asystole confirmed in at least 2 leads). Even then, it's not a guaranteed fact that the patient is dead and thereby negating any attempts to resuscitate.

I'll pronounce a blunt trauma arrest without looking at an ECG. Or a high velocity round to the head. Obvious death is... obvious. The situation here is difficult to judge due to a lack of information.

A small caliber entrance wound to the temple, resulting in pulselessness, isn't going to get worked by the majority of paramedics in the systems I've worked in. But this is a grey area. Some people will work these patients. Because it is possible that the bullet has only damaged higher structures, that it's just damaged the cerebrum without hitting a major vascular structure. It might be survivable. The absence of circulation strongly suggests otherwise, but I can understand how some medical directors might not like to give the ability to make that decision.

Put the same wound in the thorax, and it's a workable code, for sure. I think you'll find MDs who will argue both sides of this.

What got my dander up is the way it was dismissed with the statement "It's the PHTLS answer". Yes, in my opinion, it SHOULD have been handled better, and at least offered WHY this was the correct answer.

That's a bullshit response. But it's also why PHTLS is bullshit. The instructors are only as good as the instructor training course and selection process. This sort of situation is also why PHTLS / ITLS, if they were decent courses, would require that you had at least a resident on site to deal with these sorts of questions. Instead they're just a quixotic hoop you have to jump through every couple of years for recertification or continuing employment requirements.

If the course material is going to overlap from several different general categories, (ACLS, PALS, GEMS, PHTLS, etc), shouldn't the modalities of treatment also be overlapping? Or do you advocate treating the patient based on whatever modality you choose at the moment? If so, then by what criteria would you base that decision on?

I think the criteria you have to use are an actual understanding of the medicine involved, hopefully received through a decent initial training program, and continuing education (I realise that this is optimistic). I think this should be supplemented by reading the research literature to get a more nuanced understanding and to appreciate areas of changing practice. And ultimately, your treatment has to be based upon protocol or medical control guideline, and the commonly accepted practices in your area. Because like it or not, we're not physicians, and we're all answerable to someone if we decide to break with current practice standards.

Part of the trick to this, is knowing what you can and can't do, in your local area. It's not always clear. It's not always scientific, or consistent. But learning to navigate within these limitations is part of the process of being a paramedic.

As medics what would you guys do?

I'm not currently working in the field, so I may be a little out of touch, but I wouldn't start resuscitation on this patient.

Edited February 10, 2012 by systemet

[nypamedic43]

As a student I was confused by this as well. The course was taught by what the state wanted and we all had problems with that because we wanted to do what our local protocols wanted us to do. The 2 are incompatible. Then add ITLS, PALS and ACLS on top of that, who all wanted us to do what they wanted. It makes your head spin.

The bottom line is you have to throw out local protocols and in some cases the state ones as well. THEN once you pass your paramedic and get certified...you go by your local protocols and what the other classes want. I don't envy where you are Brett, I've been there and would rather go to the dentist than go through it again.

Here in the region that I am in, in order to pronounce a patient dead, there has to be signs of injury that are incompatible with life and then we have to call medical control. Crazy huh?

I would love to see a national standard but I doubt that it will ever happen. Too many states want it done thier way or will change things at the local level. It all depends on your Medical Director and what he is comfortable with EMS doing on his license. If he wants a phone call to pronounce someone, that is what he/she will get. Regardless of what the state says we can do.

I agree that the instructor could have handled the question better however he is going by what the PHTLS manual wants him to go by. We may not agree with it and argue the point but he is teaching what PHTLS wants and not what the state or local region wants.

And for the record I wouldnt have worked this patient. He is dead and I cant fix that.

[Kiwiology]

we're not physicians...

Die words die!

I know what you mean, i.e. you do not have an unrestricted scope to practice medicine but to take another flip, the "we are not doctors!" line just makes my blood boil.

Much professional advancement comes from embracing knowledge and being able to apply it; I'm not a Physician and many non-Physician Paramedics and other healthcare professionals I know can hold intelligent conversations with the Physician collegiate; for example just today I was discussing Carry-Comb's murmur, meningococcial septicaemia and ceftriaxone for Paramedics with a Consultant Physician; I've told a House Surgeon if he doesn't stop embarrassing himself by being an arrogant wanker I'm going to have to start arguing biochemistry with him to show him that he isn't the only educated person in the room.

Far from it to be for me to talk myself up (shit I'm just so wonderful aren't I tho?, not like that drunk fucking white trash piece of shit Dwayne, man, he's in fucking Niue or some shit and he doesn't even swim down to visit, arrogant prick!) but rather the examples I have given mean that knowledge is free and non-discriminatory; if you (rhetorical) want to get away from alphabet soup classes and "contact medical control" then there needs to be some serious investment in education and professional progression; tell the NAEMT to go suck themselves off and get a real representational and educational body; vis Canadian colleges' of Paramedics (oh man Squint better not see this or he'll never shut the fuck up about ACoP lulz)

The bottom line is you have to throw out local protocols and in some cases the state ones as well. THEN once you pass your paramedic and get certified...you go by your local protocols and what the other classes want. I don't envy where you are Brett, I've been there and would rather go to the dentist than go through it again.

This. Oh and I like going to my dentist, he is an expert practitioner; I just don't like the fees he charges

It all depends on your Medical Director and what he is comfortable with EMS doing on his license. If he wants a phone call to pronounce someone, that is what he/she will get. Regardless of what the state says we can do.

This ... makes me sad

Edited February 10, 2012 by kiwimedic

[DFIB]

What kind of corroborating signs are you looking for? Do you think it will make a difference? The subject is pulseless, apneic with a hole in his/her head. S/he is dead.

It is obvious to me that the PHTLS question is not the clearest or best structured question that I have seen. Not having taken the PHTLS I once again can only imagine that it referred to a specific point that the curricula wanted to make. It is definitely a question that could benefit from more detail that would limit individual interpretation.

I will have to assume that the question in the OP is referring to an unresponsive patient that is pulseless and apneic that recieved a GSW recently or immediately before the medics arrival. This assumption would exclude the late signs of death such as Liver Mortis, Rigor Mortis, and decomposition.

Being that not all GSW to the head are incompatible with life the definition of "obvious" comes into play. If we are meant to understand by "obvious" that it is a wound incompatible with life then we would include it as a sign of death as well.

Low body temp, fixed and dilated pupils, pallor mortis, which are presumptive signs of death would help to make a diagnosis and would definitely be considered in my diagnosis.

This is all somewhat rhetorical for me because as a basic I don't get to make diagnosis of death so this is a complicated and frustrating point for me.

Edited February 10, 2012 by DFIB

[systemet]

This is all somewhat rhetorical for me because as a basic I don't get to make diagnosis of death so this is a complicated and frustrating point for me.

That would be / was frustrating. Most places, even as a medic, you're not pronouncing death, you're just deciding not to resuscitate, which is somehow different. Someone else, usually the coroner / medical examiner gets to sign the actual death certificate.

Die words die!

I know what you mean, i.e. you do not have an unrestricted scope to practice medicine but to take another flip, the "we are not doctors!" line just makes my blood boil.

I understand where you're coming from. I've come to peace with this over time. It's frustrating, but we're not equals, and it's unlikely we're going to have an equal voice any time soon.

The guys in your part of the world have made some amazing steps towards professionalising EMS. Unfortunately a lot of other places are quite far behind. I can only dream of a time where every new paramedic in the US or Canada has a Bachelor's degree.

(snip)

the examples I have given mean that knowledge is free and non-discriminatory; if you (rhetorical) want to get away from alphabet soup classes and "contact medical control" then there needs to be some serious investment in education and professional progression; tell the NAEMT to go suck themselves off and get a real representational and educational body; vis Canadian colleges' of Paramedics (oh man Squint better not see this or he'll never shut the fuck up about ACoP lulz)

I agree very strongly with the bolded phrase, and the general idea that those of us working in EMS, at all levels, have a responsibility to educate ourselves further and push for change.

I have always worked in systems where paramedics have had self-governance (or at least the impression of it), and a professional college under various names has had the ability to manage registration / licensure, continuing education, and deal with conduct & competency issues, so I may lack perspective on what it means not to have this.

But I will say that the concept of a professional college has often been better than the reality. I'm not suggesting that the alternatives are better. More that just because it exists, doesn't mean it works well, or is even remotely functional. Squint might have less candid words.

All the best.

[systemet]

Squint might have less candid words.

This should have been "more candid", of course.